Physician offices have seen a dramatic increase in telehealth visits during the COVID-19 pandemic. This development has raised questions regarding the appropriate standard of care when performing a telehealth examination, in particular the “physical examination.” Naturally this blog can never supplant the physician’s expertise in evaluating patients. As in other contexts, physicians practicing telemedicine should strive to act reasonably to provide quality patient care.

Reasonableness

Physicians must always follow this standard of care when conducting examinations.  To avoid potential medical malpractice claims, physicians are obligated to act “in accordance with the prevailing professional standard of care by a reasonably prudent similar health care provider.” See, e.g., Fla. Stat. § 766.102(2)(a). The standard for telehealth examinations is no different. The Florida telehealth statute states: “A telehealth provider has the duty to practice in a manner consistent with his or her scope of practice and the prevailing professional standard of practice for a health care professional who provides in-person health care services to patients in this state.” Fla. Stat. § 456.47(2)(a).

Many providers are unsure how to provide the same standard of care during telehealth examinations without the face-to-face physical examination that they provided during in-person visits. The American Medical Association (AMA) encourages physicians to recognize the limitations of telehealth and “ensure that they have the information they need to make well-grounded clinical recommendations [ ].” AMA Code of Medical Ethics Opinion 1.2.12. Additionally, the AMA suggests that if telehealth does not appear to be appropriate for the patient – it should not be utilized.

The Telehealth Ten

The authors of a recent American Journal of Medicine article, “The Telehealth Ten: A Guide for a Patient-Assisted Virtual Physical Examination,” attempts to address physicians’ concerns. “The Telehealth Ten” list assists physicians in conducting thorough virtual visits. The article outlines objective questions for the physician in this “patient-assisted physical examination.” The categories of the Telehealth Ten are listed below. The details within the above-referenced article can assist physicians in obtaining a clearer picture of a patient’s medical issues during telehealth sessions.

• Step 1: Vital Signs: Think wearable devices, prior medical assisted measurement by ancillary staff, or even questionnaires to be answered by the patients in a secure environment.
• Step 2: Skin: Have the patient perform a self-assessment and identify any new bruises, rashes, lacerations, psoriasis plaques.
• Step 3: Head, Eyes, Ears, Nose, and Throat: Can the patient hear you?  Is the patient’s vision and sense of smell appropriate?
• Step 4: Neck: Have patients look over both shoulders and describe pain or limitations. Do they have pain upon swallowing?
• Step 5: Lungs: Does the patient exhibit cough, wheezing, or impairment upon deep respiration?
• Step 6: Heart: Wearable devices may provide the most definitive results, but vital signs are a first step.
• Step 7: Abdomen: If tender or distended, the patient may need to have an in-person evaluation.
• Step 8: Extremities: “Do you have warm or cold fingertips or toes? Is one calf more swollen than the other?  Put your hands around and check them.”  Ask the patients to show you.
• Step 9: Neurological: Do the patients exhibit any hand or arm tremors or any proximal leg weakness as they rise from a seated position?
• Step 10: Social Determinants: Does the patient report any changes in physical activity, sleep, stress, support from others? Ask the patients if they get enough food and medicine and if they are safe at home.
• The doctor will see you now.

Telehealth is a huge advantage for physicians and a convenience for patients. The federal government has expanded Medicare coverage of telehealth services to encourage physicians and patients to use them to avoid the risks of contracting COVID-19. (See here). The list of covered telehealth services is continually expanding. The Centers for Medicare & Medicaid Services announced on October 14, 2020, that they added 11 new services to those that Medicare will pay for during the COVID-19 Public Health Emergency. (See here). Recognizing the advantages of telehealth, President Trump issued an Executive Order on August 3, 2020 that makes many of the COVID-19 telehealth policies permanent. Accordingly, physicians should now ensure that they know how to properly conduct telehealth examinations so the appropriate standards of care are met.